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Coding Q&A: What to Do When Patients Request Procedures Medicare Doesn’t Cover

March 01, 2012

Question:

Medicare seems to be issuing more and more restrictive coverage policies. What if my patient demands access to a procedure for indications not supported by Medicare and is willing to pay directly for these services? Can I bill my patient, or would this violate my Medicare participation agreement?

Answer:

In order to avoid violating your Medicare participation agreement you must have thepatient complete an Advanced BeneficiaryNotice (ABN). Without this notice, you may not charge your patient for non-covered services.

An ABN is written notice provided to a Medicare beneficiary by a physician, provider, or supplier when he or she believes Medicare will deny a portion or all of the services because of medical necessity or frequency of theservice. It is important to note that ABNs should not be used when Medicare never covers a particular service.

Rather, an ABN should be used when Medicare does cover the service for some diagnoses, but the provider believes it will not be covered for a particular situation. Medicare Part B has combined the two different ABN forms and the Notice of Exclusions from Medicare Benefits (NEMB) form into a new form, CMS-R-131, for providers to use. The current form and official guidance documents regarding the execution of these forms can be found on the Medicare Web site at https://www.cms.gov/BNI/02_ABN.asp.

It is important to confirm you are using the latest version of the form and that you complete the following fields:

Top of the form: Notifiers and Patient Name

Identification Number

Center of form: List items, Reason for Denial, and Cost

The ABN form includes an option that supports submission of a claim, so that CMS can “make an official decision on payment.” Modifier –GA must be appendedto any claim submitted for which there is a properlyexecuted ABN form. This communicates to the carrier that an ABN has been executed and that the patient accepts responsibility.

-GA Item or service expected to be denied as not reasonable and necessary and Advanced Beneficiary Notice (ABN) on file: The -GA modifier is used when it is expected that Medicare will deny a service as not reasonable and necessary and an ABN signed by the beneficiary has been obtained in advance of the procedure.

Please note: SCAI is committed to making every reasonable effort to provide accurate information regarding the use of CPT®, and the rules and regulations set forth by CMS for the Medicare program. However, this information is subject to change by CMS and does not dictate coverage and reimbursement policy as determined by local Medicare contractors or any other payor. SCAI assumes no liability, legal, financial, or otherwise, for physicians or other entities who utilize this information in a manner inconsistent with the policies of any payors or Medicare carriers with which the physician or other entity has a contractual obligation. CPT codes and their descriptors are copyright 2012 by the American Medical Association.

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